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Dity / Service Vendor Information 1. BIDDING / PROPOSING COMPANY NAME Phone ( ) Toll Free Phone FAX ( ) ( ) E-Mail Address Address City 2. State Zip + 4 Name the person to contact for questions concerning this bid / proposal. Title Name Phone ( ) Toll Free Phone FAX ( ) ( ) E-Mail Address Address City 3. State Zip + 4 Any vendor awarded over $25,000 on this contract must submit affirmative action information to the department. Please name the Personnel / Human Resou.

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